ML18033A586
| ML18033A586 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry  |
| Issue date: | 07/24/1987 |
| From: | George Adams, Richards J TENNESSEE VALLEY AUTHORITY |
| To: | |
| Shared Package | |
| ML082340470 | List:
|
| References | |
| 30900, 30900-V03-R01, 30900-V3-R1, NUDOCS 8902150286 | |
| Download: ML18033A586 (70) | |
Text
EMPLOYEE CONCERNS SPECIAL PROG VOLPLANE3 OPERATIONS CATEGORY SVBCATEGORY REPORT 30900 ENGINEERING UPDATED TVA NUCLEAR POWER
0
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT TYPE:
Subcategory TITLE:
Engineering REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 1 OF 27 REASON FOR REVISION:
Reformat to conform with revision 4 of ECTG Program Manual, SRP comments and inclusion of final corrective action plans.
PREPARED BY:
PREPARATION Glenn Adams/Jon Richards SIGNATURE D TE PEER:
(Note:
Evaluator List in Attachment I)
REVIEWS SIGNATURE ATE S
NATURE CONCURRENCES ATE SIGNATURE DATE CEG-H:
~
SRP:
r SIGNATUR -/
~77< /Q 7 DATE APPROVED BY:
a-zs-as
)
ECSP MANAGER DATE MANAGER OF NUCLEAR POWER CONCURRENCE (FINAL REPORT ONLY)
DATE
=SRP Secretary's signature denotes SRP concurrences are in files.
4342T
- Preface, Glossary, and List of Acronyms for ECTG Subcategory Reports HISTORY OF REVISION REV NUMBER PAGES REVISED REASON FOR CURRENT REVISION To clarify that one or more attachments will help the reader find where a-particular concern is evaluated
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 FRONT MATTER REV:
3 PAGE i OF viii Preface This subcategory report is one of a series of reports prepared for the Employee Concerns Special Program (ECSP) of the Tennessee Valley Authority (TVA).
The ECSP and the organization which carried out the program, the Employee Concerns Task Group (ECTG), were established by TVA's Manager of Nuclear Power to evaluate and report on those Office of Nuclear Power (ONP) employee concerns filed before February 1, 1986.
Concerns filed after that date are handled by the ongoing ONP Employee Concerns Program (ECP).
The ECSP addressed over 5800 employee concerns.
Each of the concerns was a
formal, written description of a circumstance or circumstances that an employee'hought was unsafe, unjust, inefficient. or inappropriate.
The mission of the Employee Concerns Special Program was to thoroughly investigate all issues presented in the concerns and to report the results of those investigations in a form accessible to ONP employees, the
- NRC, and the general public.
The results of these investigations are communicated by four levels of ECSP reports:
- element, subcategory,
- category, and final.
Element reports, the lowest reporting'evel, will be published only for those concerns directly affecting the restart of Sequoyah Nuclear Plant's reactor unit 2.
An element consists of one or more closely related issues.
An issue is a potential problem identified by ECTG during the evaluation process as having been raised.in one or more concerns.
For efficient handling, what appeared to be similar concerns were grouped into elements early in the program, but issue definitions emerged from the evaluation process itself.
Consequently, some elements did include only one, issue, but often the ECTG evaluation found more than one issue per element.
Subcategory reports summarize the evaluation of a number of elements.
- However, the subcategory report does more than collect element level evaluations.
The subcategory level overview of element findings leads to an integration of information that cannot take place at the element level.
This integration of information reveals the extent to which problems overlap more than one element and will therefore require corrective action for underlying causes not fully apparent at the element level.
To make the subcategory reports easier to understand, three items have been placed at the front of each report:
a preface,'
glossary of the terminology unique to ECSP reports, and a list of acronyms.
Additionally, at the end of each subcategory report will be a Subcategory Summary Table that includes the concern numbers; identifies other subcategories that share a concern; designates nuclear safety-related, safety significant, or non-safety related concerns; designates generic applicability; and briefly states each concern.
Either the Subcategory Summary Table or another attachment or a combination of the two will enable the reader to find the report section or sections in which the issue raised by the concern is evaluated.
TVA, EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 FRONT MATTER REV' PAGE ii OF viii The subcategories are themselves summarized in a series of eight category reports.
Each category report reviews the major findings and collective significance of the subcategory reports in one of the following areas:
management and personnel relations industrial safety construction material control operations quality assurance/quality control welding engineering A separate report on employee concerns dealing with specific contentions of intimidation, harassment, and wrongdoing will be released by the TVA Office of the Inspector General.
Just as the subcategory reports integrate the information collected at the element level, the category reports integrate the information assembled in all the subcategory reports within the category, addressing particularly the underlying causes of those problems that run across more than one subcategory.
A final report will integrate and assess the information collected by all of the lower level reports prepared for the
- ECSP, including the Inspector General's report.
For more detail on the methods by which ECTG employee concerns were evaluated and reported, consult the Tennessee Valley Authority Employee Concerns Task Group Program Manual.
The Manual spells out the program's objectives,
- scope, organization, and responsibilities.
It also specifies the procedures that were followed in the investigation, reporting, and closeout of the issues raised by employee concerns.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 FRONT MATTER REV:
2 PAGE iii OF viii ECSP GLOSSARY OF REPORT TERMS~
classification of evaluated issues the evaluation of an issue leads to one of the following determinations:
Class A:
Issue cannot be verified as factual Class B:
Issue is factually accurate, but what is described is not a
problem (i.e., not a condition requiring corrective action)
Class C:
Issue is factual and identifies a problem, but corrective action for the problem was initiated before the evaluation of the issue was undertaken Class D:
Issue is factual and presents a problem for which corrective action has
- been, or is being, taken as a result of an evaluation Class E:
A problem, requiring corrective action, which was not identified by an employee
- concern, but was revealed during the ECTG evaluation of an issue raised by an employee concern.'ollective si nificance an analysis which determines the importance and consequences of the findings in a particular ECSP report by putting those findings in the proper perspective.
concern (see "employee concern" )
corrective action steps taken to fix specific deficiencies or discrepancies revealed by a negative finding and, when necessary, to correct causes in order to prevent recurrence.
criterion
( lural:
criteria) a basis for defining a performance,
- behavior, or quality which ONP imposes on itself (see also "requirement").
element or element re ort an optional level of ECSP report, below the subcategory level, that deals with one or more issues.
'em lo ee concern a formal, written description of a'ircumstance or circumstances that an employee thinks unsafe, unjust, inefficient or inappropriate; usually documented on a K-form or a form equivalent to the K-form.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 FRONT MATTER REV:
2 PAGE iv OF viii evaluator(s) the individual(s) assigned the responsibility to assess a specific grouping of employee concerns.
~findin s includes both statements of fact and the judgments made about those facts during the evaluation process; negative findings require corrective action.
issue a potential problem, as interpreted by the ECTG during the evaluation
- process, raised in one or more concerns.
K-form (see "employee concern")
evaluation judgment or decision may be based.
root cause the underlying reason for a problem.
=Terms essential to the program but which require detailed definition have been defined in the ECTG Procedure Manual (e.g.,
- generic, specific, nuclear safety-related, unreviewed safety-significant question).
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 FRONT MATTER REV:
2 PAGE v OF viii Acronyms AI AISC Administrative Instruction American Institute of Steel Construction ALARA ANS ANSI As Low As Reasonably Achievable American Nuclear Society American National Standards Institute ASME ASTM American Society of'echanical Engineers American Society for Testing and Materials AWS BFN BLN CA/
CAR CATD CCTS American Welding. So cie ty Browns Ferry Nuclear Plant Bellefonte Nuclear Plant Condition Adverse to Quality Corrective Action Report Corrective Action Tracking Document Corporate Commitment Tracking System CEG-H Category Evaluation Group Head CFR CI CMTR COC DCR Code of Federal Regulations Concerned Individual Certified Material Test Report Certificate of Conformance/Compliance'esign Change Request DNC Division of Nuclear Construction (see also NU CON)
TVA, EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT lABQER'0900 FRONT MATTER REV:
2 PAGE vi OF viii DNE DNQA DNT Division of Nuclear Engineering Division of Nuclear Quality Assurance Division of Nuclear Training DOE Department of Energy DPO DR ECN ECP ECP-SR ECSP ECTG EEOC EMRT EN DES ERT FCR FSAR FY GET HCI HVAC INPO IRN Division Personnel Officer Discrepancy Report or Deviation Report Engineering Change Notice Employee Concerns Program Employee Concerns Program-Site Representative Employee Concerns Special Program Employee Concerns Task Group Equal Employment Opportunity Commission Environmental Qualification Emergency Medical Response Team Engineering Design Employee'Response Team or Emergency
Response
Team Field Change Request Final Safety Analysis Report Fiscal Year General Employee Training Hazard Control Instruction Heating, Ventilating, Air Conditioning Installation Instruction Institute of Nuclear Power Operations Inspection Rejection Notice
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 FRONT MATTER REV:
2 PAGE vii OF viii L/R Labor Relations Staff'RAI'odifications and Additions Instruction MI MSPB MT
'NCR NDE NPP NPS NQAM NRC NSB NSRS NU CON Maintenance Instruction Merit Systems Protection Board Magnetic Particle Testing Nonconforming Condition Report Nondestructive Examination Nuclear Performance Plan Non-plant Specific or Nuclear Procedures System Nuclear Quality Assurance Manual Nuclear Regulatory Commission Nuclear Services Branch Nuclear Safety Review Staff Division of Nuclear Construction (obsolete abbreviation, see DNC)
NUMARC Nuclear Utility Management and Resources Committee OSHA ONP OWCP Occupational Safety and Health Administration (or Act)
Office of Nuclear Power Office of Workers Compensation Program PHR PT QA QAP QC QCI Personal History Record Liquid Penetrant Testing Quality Assurance Quality Assurance Procedures Quality Control Quality Control Instruction
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 FRONT MATTER REV:
2 PAGE viii OF viii QCP QTC RIF SQN SI SOP SRP SWEC TAS T&L TVA TVTLC UT WBECSP WBN Quality Control Procedure Quality Technology Company Reduction in Force Radiographic Testing Sequoyah Nuclear Plant Surveillance Instruction Standard Operating Procedure Senior Review Panel Stone and Webster Engineering Corporation Technical Assistance Staff Trades and Labor Tennessee Valley Authority Tennessee Valley Trades and Labor Council Ultrasonic Testing Visual Testing Watts Bar Employee Concern Special Program Watts Bar Nuclear Plant WR Work Request or Work Rules Workplans
Revision 1
ENGINEERING Subcategory Report 30900 Ezecutive Summar I.
SUMMARY
OF ISSUES The Engineering Subcategory of the Operations Category contains 11 concerns which raise 11 issues.
These issues raise questions about engineering programs and processes such as the workplan process, configuration control, control of consumables, and engineering training at all TVA sites.
Four of these issues were found not to be validated.
One issue was factual, but did not require corrective action.
Three issues were factual and I
identified a problem, but corrective actions were initiated before the I
employee concerns evaluation of the issue was undertaken.
These issues I Rl deal with a) inadequate work control on the fire protection system at
- WBN, b) inaccessible drawings on backshifts at WBN, and c) lack of acceptance criteria in procedures at WBN.
Three issues were factual and presented I
problems for which corrective actions have
- been, or are being, taken as a
result of an employee concerns evaluation.
These issues deal with a)
I inadequate control of Teflon tape at SQN and BFN, b) lax inspection criteria at WBN leading to incomplete hardware modifications, and c) technical support engineers at WBN not getting adequate formal training.
II.
SUMMARY
OF FINDINGS IR1 Of the 11 issues evaluated, eight were found not to be problems because corrective actions were either not needed or were already in place, but three issues revealed problems for which corrective action was required:
I I Rl 1.
WBN had two potential problems in the implementation of training for System Engineers.
These problems were believed to be generic to SQN and BFN as well.
2.
At WBN, a deficiency (a violation of a design, construction, or operation requirement) was found pertaining to the potential for loss of configuration control in implementing the Maintenance Request (MR) process.
3.
All sites had deficiencies which allowed Teflon thread sealing tape to be used in violation of General Construction Specifications.
Page 1 of 2 4342T
Revision 1
SUMMARY
OF COLLECTIVE SIGNIFICANCE A collective assessment of the findings for this subcategory showed that the issues reflected upon plant-wide programmatic deficiencies and maintenance practices more fully addressed in Subcategory Report 30700, "Nuclear Power Site Programs/Procedures,"
and Subcategory Report 30800, "Maintenance." It was determined that a
meaningful assessment of the issues presented in this subcategory could not be accomplished without also examining the findings in the other two subcategory reports.
Therefore, it was decided that no subcategory-level conclusions would be made in this report and that the findings from this subcategory report on issues such as workplan
- process, configuration control, control of consumables, and engineering training would be analyzed more fully during the collective assessment processes on Subcategory Report 30700 and 30800.
Significant conclusions resulting from these two subcategory collective assessment processes will be escalated to the Operations-Category Report.
I Rl IV.
SUMMARY
OF ROOT CAUSES I Rl Causes for the deficiencies discussed in Section II included:
Some procedures governing engineering training and control of consumables are incomplete or fail to incorporate all technical requirements.
There have been instances of inadequate controls for temporarily altered equipment and use of consumables to ensure compliance with commitments.
V.
SUMMARY
OF CORRECTIVE ACTION With respect to Teflon tape, SQN line management committed to revising procedures and issuing a memorandum in order to clarify the restrictions on Teflon tape application.
WBN, BFN, and BLN were found to have already reviewed the use of Teflon tape and to have restricted its use.
Corporate management has been requested to revise the'division procedure manual relative to Teflon tape control.
Corporate management is also currently negotiating a test program with Oak Ridge National Laboratory for candidate thread sealant materials to conclusively qualify unrestricted sealants.
2
~
-With respect to implementation of the Maintenance Request (MR)
- process, WBN line management explained that the AI is explicit in how the maintenance request process is to be conducted and that the process provides for returning equipment to normal status as required.
Therefore, the problem perceived, by ECTG was thought to be with MR implementation rather than with the MR form itself.
3.
With respect to system engineering training, WBN and corporate management have committed to a review of engineering training requirements and have initiated some procedural changes.
Page 2 of 2
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 2
OF 27 1.0 CHARACTERIZATION OF ISSUES 1.1 Introduction The Engineering Subcategory is comprised of 11 employee concerns that raise 11 issues dealing with Engineering Training and Engineering programs which control plant processes or equipment.
The subcategory originally had been developed to look at the Engineering support part of the various plants'rganizations and had consisted of five higher order groups of related
- concerns, called elements.
- Later, however, two of these five elements were deleted as the elements'oncerns were transferred to more appropriate subcategories.
- Also, as findings were generated on the remaining three elements, it became evident that the issues reflected more on plant-wide programmatic deficiencies and maintenance practices more fully addressed in Subcategory Report
- 307, "Nuclear Power Site Program/Procedures,"
and Subcategory Report
- 308, "Maintenance," rather than on Engineering support functions, Therefore, references to these two other subcategories are made throughout this report.
In this section of the report, each of the three existing elements is presented with a brief overview of the issues.
1.2 Descri tion of Issues The issues have bee'n combined into higher-order
- groups, called
- elements, to aid in identifying and evaluating related issues.
In this section of the report, each element is presented with-a brief overview of its issues.
The employee concern numbers for each issue are listed under each issue title.
1.2.1 Element 309.01 - Ade uac of Procedures Issue 309.01-1
- Mana ement did not re uire Fire Protection S stem drained before maintenance IN-85-595-008 The CI reported that management at WBN did not request the fire protection system be drained before craft began drilling on the shutdown lines.
Issue 309.01-2
- Backshifts have no access to lant drawin s
IN-85-704-002 It was reported by the CI that 2nd and 3rd shifts at WBN do not have access to drawings related'to'instrumentation activities.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 3
OF 27 Issue 309.01 Procedures lack clarit and acce tance criteria IN-85-825-002 The CI reported that several procedures at WBN need to have portions rewritten for clarity or more defined acceptance criteria.
I iR1 I
Issue 309.01 Teflon ta e is not ade uatel controlled IN-85-977-001 This concern addresses the implementation of identify and replace the Teflon tape used on Coolant System and those systems that return I
I Rl WBN programs to the Reactor to the RCS.
Issue 309.01 Technical Instructions TI) are incorrect and incom lete WBN-243NS The CI alleged that WBN TIs are incorrect or incomplete, citing one specific TI.
1.2.2 Element 309.04 - Procedure Violations-Issue 309.04-1 Lax ins ection criteria I
IRl I
IN-85-984-002 I Rl For Element 309.04 one employee concern at WBN involves a
lack of adherence to existing procedures within Nuclear Power which apparently led to modifications to permanent plant ladders without revision to appropriate drawings and in another case led to the improper reassembly of a shielding enclosure.
Issue 309.04-2
= Violation of Out-of-Service ta s
XX-85-122-023 I Rl At Bellefonte Nuclear Plant (BLN), lack of adherence to existing procedures was alleged by the CI who reported Office of Nuclear Power
<ONP) personnel violating out-of-service tags on valves and electrical equipment, thus jeopardizing personnel safety.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 4
OF 27 1.2,3 Element 309.05 - En ineerin Trainin Issue 309.05 Trainin on actual lant e ui ment IN-85-495-001 The CI expressed a need at WBN for more training on the specifics of plant equipment.
Issue 309.05 Personnel erformin technical reviews are not ro erl trained IN-86-091-001 The CI expressed a vague concern at WBN regarding training of personnel performing technical reviews.
Issue 309.05 S stem en ineers do not et ade uate formal
~trainin IN-86-209-005 The CI expressed a broad concern at WBN regarding lack of systems training which could lead to design control errors.
Issue 309.05 Inex erienced Shift Technical Advisor (STA)
Course instructors IN-86-209-012 The CI reported individuals at WBN with no STA experience instructing STA classes.
To locate the issue in which a particular concern is evaluated, please consult the following attachments:
Attachment A, Subcategory Summary Table, List of Concerns by Element/Issue r
2;0 EVALUATION PROCESS 2.1 General Methodolo The evaluation of this subcategory was conducted according to the Evaluation. Plan for the Employee Concerns Task Group and the Evaluation Plan for the Operations Group.
The concern case files were reviewed.
Source documents were researched and interviews conducted in order to identify the requirements and criteria which
II TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 5
OF 27 applied to the issues raised by the concerns.
The issues were evaluated against the identified requirements and criteria to, determine findings.
A collective significance analysis was conducted; causes were indicated for negative findings; and corrective action for the negative findings was initiated or determined to have already been initiated.
2.2 S ecific Methodolo During the element evaluations, the evaluators reviewed applicable sections from the following baseline requirements documents:
Final Safety Analysis Report (FSAR) at WBN; applicable regulatory requirements including NUREGs; =and ANSI Standards.
To ensure consistency and implementation of the requirements found in these documents, the evaluators reviewed applicable Standard Practices, Administrative Instructions (AI), Surveillance Instructions (SI),
Technical Instructions, Quality Control Instructions (QCI) and procedures, data packages, Maintenance Requests (MRs),
and records.
In addition, the evaluators reviewed files which had been expurgated by NRC, as well as WBN plant staff reports, Nuclear Safety Review Staff (NSRS) reports of concerns previously investigated, and interoffice memoranda at WBN, SQN, BLN, and BFN.
IRl The evaluators conducted informal interviews with cognizant personnel when required either to verify document-based findings or to provide nondocument-based evaluation input.
Interviews were conducted with personnel in ONP; Steamfitters at
- SQN, Power Stores Management at BFN; the Instrument Maintenance (IM) Engineer at WBN; Electrical and Mechanical Superintendents, General
- Foremen, and Shift Engineers in both DNC and ONP organizations at BLN; the BLN Employee Concerns Program Site Representative (ECP-SR);
and STA course students at SQN.
From their element evaluation findings, the evaluators identified specific deficiencies and analyzed them for perceived root causes at the element level.
A final determination was made on whether or not each specific deficiency was safety-related.
The evaluators initiated CATDs for the specific deficiencies that had been identified during the element evaluations.
The evaluators documented their findings, specific deficiencies, and perceived root causes in element reports written in accordance with the Operations Category Evaluation Plan.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
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1 PAGE 6
OF 27 3.0 FINDINGS NOTE:
Generic applicability statements are included for concerns which are classified as being potentially safety-related or safety-significant as denoted on Attachment A.
IR1 I
iR1 I
3.1 Element 309.01 - Ade uac of Procedure I R1 Issue 309.01 Mana ement did not re uire Fire Protection S stem drained before maintenance (WBN)
Concern IN-85-595-008 pertained to management not requesting the Fire Protection System to be drained prior to drilling on the system.
The evaluator found that during the 1983-1984 timeframe, an isolated incident occurred which fit the description of the concern.
Craft personnel informed the evaluator that a new system had been installed in the fire protection system which used instrument air to detect leakage in the sprinkler system.
An Auxiliary Unit Operator (AUO), unaware of the new system, did not ensure that the air pressure was bled off before authorizing work to commence.
Therefore, approximately four gallons of muddy water (from a low spot in the lines) spilled on the floor while craft personnel were working on the fire protection.
IR1 Conclusion I Rl The issue was factual, identified a problem, but corrective action for the problem was initiated before the evaluation of the concern was undertaken.
The AUOs were subsequently trained on the system and the evaluator could find no recurrence of the 'incident.
No further corrective action was determined to be necessary.
IRl I Rl I
I I
Issue 309.01-2 Backshifts have no access to lant drawin s
(WBN)
One of the five WBN concerns for the 'adequacy of procedures (IN-85-704-002) pertained to the inaccessibility of plant drawings to backshift personnel.
During the evaluation it was learned that Watts Bar Nuclear Plant Site (WBNPS) document control section opened a 24-hour-a-day, 7-days-a-week document control center.
Instrumentation drawings for plant operatibns and maintenance are available for use by individuals working all three shifts.
No further corrective action was determined to be necessary.
I Rl Conclusion I R1 This issue was factual, identified a problem, but corrective action IRl for the problem was initiated before the evaluation of the concern.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 7
OF 27 Issue 309.01 Procedures lack clarit and acce tance criteria WBN)
Another concern, IN-85-825-002, alleged inadequacy in TVA procedures to provide clear instructions and well-defined acceptance criteria.
Two examples were provided:
Technical Instructions (TI)-27 and Modifications and Addition Instruction (MGAI)-14.
NSRS report I-85-339-WBN had previously investigated this concern.
This report concurs with the findings of the NSRS report.
NSRS found deficiencies in TI-27 to have been already addressed under the WBN Quality Assurance Program.
As a result of the QA corrective
- actions, the TI was adequately revised to include measures to direct the performance of troubleshooting activities.
The other example provided by the CI was not validated by the NSRS investigation.
I I Rl Contrary to the allegation, Revision 5 of MRAI-14 dated May 15, 1985 did not use the term "Qualified Personnel."
The instruction did provide explicit references on who could sign-off on data sheets, namely QC Inspectors and Craft Foremen.
Conclusion This issue was factual, identified problems, but corrective actions for the problems were initiated before the evaluation.
No further corrective action was determined to be necessary.
Generic A licabilit This concern was evaluated at the site of the concern (WBN). It was determined that the issue was related to specific WBN procedures.
Adequate corrective action had'een implemented prior to the ECTG evaluation.
No other site evaluations are necessary.
I I
/Rl I
IR1 I
=-
I I
Issue 309.01 Teflon ta e is not ade uatel controlled WBN Concern IN-85-977-001 pertained to a perception that TVA defaulted on a commitment to identify and replace misapplications of Teflon tape on the Reactor Coolant Systems (RCS).
NSRS Report I-85-383-WBN reviewed the usage of Teflon tape with respect to Construction Specifications.
This concern was validated by the NSRS Report and this report concurs with the NSRS Report findings.
The misapplication of Teflon tape on lines that re-enter the RCS
'on WBN units 1 and 2 was previously identified by Nonconformance Report (NCR) W-231-P.
I Rl I Rl I
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 8
OF 27 As part of the NCR corrective action measures, the WBN Office of Engineering (OE) released a memorandum requiring immediate removal of Teflon tape from specific areas of the plant and also justified use as-is in the remainder of the plant until all tape could be replaced on a no-delay-to-operations
- basis, It also stated that Teflon tape located outside the applicable RCS boundary did not pose a safety concern.
The memorandum further stated that Teflon tape would no longer be used at Watts Bar.
NSRS verified removal of Teflon tape from the Power storeroom and Construction warehouse stock.
This decision virtually eliminates any use of Teflon tape and possible future problems-in this area.
Subsequent to this memorandum, Nuclear Power removed all Teflon tape applied on the referenced applicable stainless-steel lines in unit 1.
The unit 2
portion of the NCR remains open until similar action can be accomplished on the applicable unit 2 lines, No further corrective action was determined to be necessary.
~SN A SQN evaluation was also performed for the concern pertaining, to a perception that TVA defaulted on a commitment to identify and replace misapplications of Teflon tape.
This concern was validated under NSRS Inspection Report I-85-383-WBN and was generically applied to SQN.
This report concurs with the NSRS Report findings.
The inspection found that standard practice SQA-160 had contained the restrictions on Teflon tape usage that were consistent with the General Construction Specification, but that planners,
- foremen, and engineers were not familiar enough with the standard practice 'to preclude recurrence of the problem.
This unfamiliarity was discovered in interviews with planners,
- foremen, and an engineer who had the responsibility to be knowledgeable with the requirements of the standard practice.
No working level instruction addressed the use of tape.
To address the fact that no program exists to identify and replace the existing misapplications of Teflon tape, Operating Experience Report (OER)
SQN 850088001 was initiated, This OER is also performing the task generic to all TVA nuclear sites which is to locate a suitable substitute for Teflon tape.
Subsequent to the initial evaluation and the Corrective Action Plan (CAP) received for CATD 30901-SQN-01,
.some questions were raised by the NRC.
Additional information was obtained in response to questions concerning the proposed corrective action as stated in Section 6.0.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 9
OF 27 Zt was determined that Teflon tape is not a problem if used within the environmental limits, regardless of the system on which it is used.
Revision 5 of SQA-160 removed the restriction prohibiting use of Teflon tape on any lines that will reenter the reactor system.
The removal of this requirement creates an inconsistency with the upper-tier requirements in G29, DPM N73E1 and N73M2.
The requirements in revision 5 of SQA-160 will override DPM N73E1 until the DPM is revised to reflect the same requirements.
This is allowed by plant procedure SQA-188, and a cover sheet is attached to the revision 5 of SQA-160 documenting headquarters'ndorsement'of the standard practice in lieu of the upper-tier document indicated on the cover sheet.
The cover sheet indicates that DPM N73El is overridden but does not indicate G-29 or DPM N73M2 as being overridden.
Therefore an inconsistency still exists between SQA-160 and upper-tier documents G-29 and DPM N73M2.
The requirements of G-29 are applicable to SQA-160 since G-29 is a
Division of Nuclear Construction (DNC) Document and Modifications, which is a branch of DNC, uses SQA-160.
The disposition of OER SQN 850088001 indicates an environmental drawing prerequisite will be imposed on Teflon tape usage.
A discussion with OER tracking personnel revealed that this prerequisite has not been implemented and remains an open item on the OER.
A Condition Adverse to Quality Report, (CAQR)
SQP 870155, was initiated on March 9, 1987 which identifies the lack of a "consistent policy or program to identify, control, and eliminate improper usage of Teflon tape."
It was concluded that the specific concern that no program has been established to identify and replace Teflon tape on the RCS is not valid.
- However, the issue of preventing the use of Teflon tape in all unacceptable locations was determined to be valid.
The present approach by SQN in allowing limited, 'controlled use of Teflon tape is not consistent with the WBN and BFN approach as indicated in OER SQN 850088001.
CAQR SQP 870155 identifies this inconsistency for resolution.
CATD 30901-SQN-01 was issued to SQN line management to address the lack of employee familiarity with Teflon tape usage and to address the adequacy of Standard Practice SQA-160.
CATD 30901-SQN-02 was issued to track closure of CAQR SQP-870155.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 11 OF 27 This issue at SQN and BFN was factual and presents a problem for which corrective action is being undertaken as a result of the evaluation.
This issue at BLN was not verified as factually accurate.
Issue 309.01 Technical Instructions are incorrect and incom lete (WBN)
Another concern (WBN-243NS) alleged that TIs are incorrect or incomplete, citing one specific TI where the output values in two separate instrumentation loops were expressed in units of millivolts when the actual output values were in units of kilo-pounds/hour (KBH).
The evaluator discredited the concern for one of the loops by determining its output value to be in units of degrees F; rather than either of the cited units.
The concern for the other loop was also not validated because the evaluator determined the instruction correctly expressed computer input values in millivolt units and output values as KBH.
Conclusion This issue was not verified as factually accurate.
3.2 Element 309.04 - Procedure Violation Issue 309.04 Lax ins ection criteria (WBN)
The site specific concern (IN-85-984-002) that WBN Nuclear Power (NUC PR) personnel violated procedure by modifying permanent plant ladders without revising appropriate drawings and in another
- case, improperly reassembling a shielding enclosure was validated, The first instance of procedure violation was substantiated based on evidence that two of the three cited ladders had been modified without supporting documentation.
An interview with the cognizant engineer revealed that the ladder modifications were eventually documented'by a Temporary Alteration Control Form (TACF) sometime after the concern was initiated and at least two years after the modification.
The second instance of procedure violation was substantiated based on physical evidence that the cited shielding enclosure around a
radiation monitor was -improperly reassembled as alleged.
In fact, the evaluator determined that the shields had remained improperly reassembled (disassembled) for over two years.
The initiating Maintenance Request (MR) had been kept open to document the state of disassembly of the shields;
- however, the open MR was not being tracked by any central tracking device nor was the Instrument Maintenance Engineer aware that the MR was open.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 12 OF 27 By procedures, governing Administrative Instructions required sufficient action to preclude the occurrence of this deficiency.
The Administrative Instruction which governs HRs even requires second party verification that equipment which has been temporarily altered in a manner such as this is returned to its normal condition. It further requires the completion of a TACF i.f the temporary alteration is not returned to normal.
Other associated AIs make similar provisions to track alterations.
- However, where these associated AIs, SIs, and MIs all include a step to verify the system is returned to normal, MRs do not include a specific sign-off block to reference a TACF written upon closure of the MR or to verify that the item has been returned to normal.
Although HRs do not include the specific sign-off block, it was determined that the WBN MR program requires TACFs to be referenced on the MR.
CATD 30904-WBN-01 was issued to address this discrepancy.
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The issues of workplans and configuration control are addressed more thoroughly in Subcategory Report 307.'onclusion I
I This issue was verified as factual and presents a problem for which corrective action is being taken as a result of the evaluation, I
Generic A licabilit The WBN evaluation of this concern determined the issue to be instances of procedural noncompliance and inadequate procedures limited to WBN.
No other site evaluations are necessary.
Issue 309.04 Violation of Out-of-Service ta s
(BLN)
A concern (XX-85-122-023) expressing a lack of proper recognition for equipment out-of-service tags by personnel at BLN could not be substantiated based on numerous employee interviews and a thorough review of training, documents.
The evaluator determined that all operations and construction personnel authorized to hold a
protective clearance for, equipment work are required to complete a
training class on clearance procedures once every two years.
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TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 13 OF 27 The evaluator found that additional emphasis is routinely put on protective cards at the group safety meetings in DNC and ONP organizations.
In short, the evaluator found sufficient training and instructions to ensure that all plant personnel are knowledgeable of the requirements on protective cards used at BLN.
Furthermore, interviews revealed no evidence of a widespread indifferent attitude toward protective tags or personnel safety problems related to such practices.
The evaluator found that no concerns of this. nature had been identified to the BLN Employee Concerns
- Program, indicating continued employee respect for protective cards.
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Conclusion This issue was not verified as factually accurate.
Generic A licabilit This concern was evaluated at the site of the concern (BLN) and to be not valid.
No other site evaluations are necessary.
3.3 Element 309.05 - En ineerin Trainin Issue 309.05 Trainin on actual lant e ui ment (WBN)
Concern IN-85-495-001 pertained to insufficient training for craft and engineering personnel on plant-specific equipment and was not validated.
Training for craft and engineering personnel on the specifics of plant equipment is decided by their immediate supervisors as detailed by a WBN procedure. 'his procedure also contains specific courses that may be selected by a supervisor for his/her personnel.
Additionally, the Plant Operations Training Center (POTC) publishes, on a monthly basis, the courses that are to be taught in the next month.
This notification is sent to line management at each plant and they may enroll personnel at their discretion.
- Further, there are many specialized courses offered at manufacturers'acilities that are utilized.
I Conclusion This issue was not-verified as factually accurate.
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TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER 30900 REVISION NUMBER:
1 PAGE 14 OF 27 Issue 309.05 Personnel Performin Technical Reviews are not Pro erl Trained (WBN)
Concern IN-86-091-001 is in regard to technical reviews of data being performed by personnel with neither the proper training nor expertise.
This concern was not validated based on a review of trai'ning records, particularly those training, records of Preoperational (Preop)
Test Personnel.
These individuals perform the majority of technical reviews of tests/data.
The evaluator found that the requirements for Preoperational Testing Section personnel qualifications were fully met.
Training within the section was found to be well-implemented and supported by written examinations and records validating section personnel knowledge and capability.
Conclusion This issue was not verified as factually accurate.
Issue 309.05 S stem en ineers do not et ade uate formal trainin (WBN)
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One concern (IN-86-209-005), of broad scope, pertained to WBN technical support engineers not getting adequate formal training, to prevent design control errors which could impact plant safety.
Although no instance was identified where an engineer did not understand system operations as alleged, the concern was validated based on a finding that training procedures do not adequately implement ONP training requirements for engineers, Furthermore, the evaluator found an organizational interface problem of unestablished responsibility for plant-specific training for WBN personnel in the Division of Nuclear Engineers (DNE), Division of Nuclear Construction (DNC), Division of Nuclear Quality Assurance (DNQA),
and Division of Nuclear Safety and Licensing (NSBL),
In general.
the evaluator found the training programs to be soundly structured and functional.
- However, two potential problems were identified with the training program.
One potential problem results from a Training Management, oversight that system engineers in some organizations (mentioned above) do not get site-specific training because they are not subject to the WBN governing training procedure.
Another potential problem results from the failure of
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 15 OF. 27 the WBN administrative instruction to specifically implement the requirements from TVA's Nuclear Training Program Manual.
With respect to these two potential problems, the evaluator found a
necessity for revision of the applicable administrative instruction to provide more detail with respect to training paths for engineers with system responsibility.
An additional finding was that WBN line management appeared to be behind on Orientation Phase training for engineers.
Six CATDs were issued to address the concern for inadequate formal training for engineers with system responsibility..
One CATD was issued to Corporate Training and another to POTC.
The remaining four CATDs were issued to WBN line management.
CATD 30905-WBN-01 issued to WBN line management noted that AI-10.1 does not implement the requirements of Area Plan 0202.17, and as a
- result, does not provide guidance for engineers.
- Also, CATD 30905-WBN-03 to WBN line management noted that AI-10.1 fails to provide sufficient detail on engineering training programs.
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CATD 30905-NPS-01 issued to Corporate Training noted that the WBN site procedure for technical staff training (AI-10.1) does not apply to site personnel from DNE,
- DNC, DNQA, or NSSL.
Furthermore, the CATD noted that the AI is n'ot responsive to the TVA upper tier I
procedure which specifies training for site assigned personnel (Area Plan 0202.17).
Finally, the CATD noted that there were no I
responsibilities assigned to ensure that this training program is I
accomplished.
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CATD 30905-NPS-02, which was issued to POTC, noted that a section of IR1 Area Plan 0202.17 is not accurate in that responsibility has been transferred from Supervisor, Personnel Service Staff to POTC.
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TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 16 OF 27 Conclusion I
I This issue was verified as factual, and presents a problem for which IR1 corrective action is being taken as a result of the evaluation.
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Issue 309.05 Inex erienced Shift Technical Advisor STA) Course Instructor WBN Concern IN-86-209-012 pertained to the inadequate qualification of STA Course instructors because they had little or no experience as STAs.
Investigation 309.05 SQN was performed and addressed all aspects of the concern.
The situation involved joint WBN/SQN class Shift Technical Advisor (STA) training.
Someone alleged that an STA student was scheduled to instruct a portion of the next STA class with no experience of having fulfilled the actual watch station as an STA. It was determined that two individuals,
- However, a review of these individual's qualifications indicated that they were well-prepared ior the subject matter they were to teach and their qualifications were within TVA's training instruction requ'irements.
This evaluation concurs with the, content of 309.05 SQN as presented in the SQN section below.
No problems were identified; no corrective action is necessary.
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~SN This issue was substantiated in that there were two instructors performing STA training with little or no STA experience.
- However, the evaluator found the 'qualifications of these two individuals well-matched to the subject matter assigned.
The duties assigned were also within TVA's requirements for STA instructor qualification.
Therefore, no deficiencies were identified.
Conclusion This issue was verified as factual at WBN described is not a problem.
Generic A licabilit This concern was evaluated at SQN and WBN at both sites.
No other site evaluations I
I and SQN, but what is I
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.are necessary.
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TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 17 OF 27 4.0 COLLECTIVE SIGNIFICANCE This subcategory consisted of concerns about the adequacy of engineering
- programs, adherence to procedures, and the adequacy of engineering training.
A collective assessment of the findings for this subcategory showed that the issues reflected upon plant-wide programmatic deficiencies and maintenance practices more fully addressed in Subcategory Report 30700, "Nuclear Power Site Programs/Procedures,"
and Subcategory Report 30800, "Maintenance."
It was determined that a
meaningful assessment of the issues presented in Subcategory 30900 could not be accomplished without also examining the findings in the other two subcategory reports.
Therefore, no subcategory-level conclusions were made in Subcategory 30900.
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I 5.0 ROOT CAUSE PRELIMINARY ANALYSIS I Rl Section 3.0 discussed the specific findings for each of the element I Rl evaluations of this subcategory.
This section presents'he results of an independent review and analysis done on these specific element-level findings to identify overall root causes at the subcategory level.
Patterns of recurring findings called symptoms were derived from the elements and were tested for root causes.
The root causes for all elements were then analyzed collectively to identify those occurring most frequently for the subcategory overall.
Details of the symptoms and root causes derived for each element are presented in Attachment D,
"Summary IR1 of Symptoms and Root Causes."
The review and analysis of the symptoms and root causes pointed to two subcategory level root -causes as follows:
a.
Some procedures governing engineering training and control of consumables are incomplete or fail to incorporate all technical requirements (WBN, SQN) b.
There have been instances of inadequate controls for temporarily altered equipment and use of consumables to ensure compliance with commitments (WBN, SQN)
These two subcategory level root causes derived from root cause analysis are supported by several element-level findings at two of TVA's four nuclear plants.
The first root cause is supported by a) need for revision of the WBN administrative instruction for technical staff training to provide more detail on training paths for engineers with system responsibility (section 3.3),
and b) no working, level instructions at SQN to address the use of Teflon tape (sections 3.1).
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TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900
'EVISION NUMBER:
1 PAGE 18 OF 27 Examples supporting the second root cause include a) two instances at WBN when there was improper identification of the status of temporarily altered equipment (section 3.2),
and b) use of Teflon tape at SQN in violation of upper-tier requirements (sections 3.1).
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Corrective Action Tracking Documents (CATDs) were not issued specifically on these subcategory-level root causes.
It was believed that corrective actions being taken already by line,management as part of the commitments made in the Nuclear Performance Plan were helping to address these root causes.
However, line management was expected to use the subcategory-level root cause information as an aid in preparing corrective action responses to subcategory-level CATDs that would preclude recurrence of the deficiency noted.
The ECTG's process for judging the adequacy of line corrective action response to subcategory-level CATDs included a determination of how well the applicable root causes were addressed by the response.
The significant root causes for all subcategories in the Operations category provided part of the input for determining programmatic areas of weakness at the category level and the associated causes.
In the Operations category report, these programmatic weaknesses and associated causes are presented along with a discussion of how they are being corrected through implementation of the Nuclear Performance Plan and other corrective action programs.
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6.0 CORRECTIVE ACTION 6.1 Corrective Action at Element Level 6.1.1 Element 309.01 - Ade uac of Procedures iR1 Three CATDs were issued to address problems dealing with usage of Teflon tape.
One Non-Plant-Specific (NPS)
CATD (30901-NPS-01) was issued to corporate management, and I R1 the other two CATDs (30901-SQN-01,-BFN-01) were sent to SQN and BFN line managers.
NPS CATD No.
30901-NPS-01 CATD 30901'-NPS-Ol sent to corporate. management noted that inconsistencies exist between
It also made the observation that identification.of an acceptable substitute for Teflon tape has not been aggressively pursued.
The acceptable corrective action response received from corporate management was as follows:
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 19 OF 27 "The" current status of the program to identify an approved, unrestricted thread sealant is outlined in a memorandum from W. E. Pennell to R. A. Sessoms dated February 26, 1987 (B45 870212 259).
Some of the information contained in the discussion of Concern IN-85-977-001 in Fact Sheet 309.01-WBN has been updated by a memorandum from H. B. Bounds to George Toto dated March 16, 1987 (B26 870316 001).
Site procedures on the use of Teflon tape at BFN,
- SQN, and WBN may vary somewhat, within the restrictions imposed on Teflon tape usage in G-29M and DPM N73M2, P.
S. 4.M.1.1 (R10).
Deviations from these engineering requirements are grounds for initiation of a CAQ.
Such a
CAQ is presently under review for disposition at SQN."
Excerpts from the Pennell to Sessoms memorandum referenced in the corrective action response above are as follows:
Problem "Application of Teflon thread sealant tape outside the limits imposed by G-29M and DPM N73M2 was identified at SQNP in SCRSQNNEB8525 (reference 3) and at Watts Bar in NCR W-231-P (C24 850501 104).
"In order to avoid misapplication of certain thread sealants in restricted areas, it is desirable to identify a thread sealant material(s) with the following features:
(1) Effects a seal at 650 F/2200 psia on threaded stainless steel joints to gamma radiation doses of 10 rads (2) Contains low levels of halogens,
- sulfur, and low melting point metals so that it does not promote corrosion/stress-corrosion of these joints under the above conditions (3) Is easily applied to small-diameter instrument lines by craft personnel wearing C-zone clothing (4) Provides sufficient lubricity such that galling is prevented during joint construction (5) Allows the joint to be easily disassembled for maintenance or repair work "Grafoil tape has been the recommended unrestricted material for thread sealant applications.
DNE recognizes the difficulty of applying this tape to, small-diameter lines and has been actively pursuing an alternative which will be qualified for use at temperatures up to 650 F and at doses up to 109 rads (gamma, 40-year integrated plus accident dose),
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM Interim Alternative Sealant REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 20 OF 27 "Until a usable, fully qualified, unrestricted thread sealant is identified, one alternative material which can be used on CSSC stainless steel within certain limitations is Felpro HPS.
Felpro HPS as a phenolic resin generally can withstand temperatures to 650 and doses of 107 rads (gamma).
It is, therefore, acceptable in many areas of the plant and is listed in G-29M, P.S.4.M.1.1 Certain low-halogen batches of Felpro HPS have been procured by WBN and SQN.
However, not all lots will now meet halogen limitations.
We have contacted Felpro concerning their ability to supply the HPS on a preferred lot basis with Certified Material Test Reports (CMTRs).
Although Felpro is interested in pursuing this capability, they presently do not exercise sufficient batch chemistry control to be able to supply CMTRs.
Until they have this capability, TVA will have to continue to conduct in-house chemical analyses on each batch/lot ordered.
Additional Pros ective Sealant "Union Carbide has recently produced a laboratory formulation of Grafoil Paste consisting of Grafoil particles in a linseed oil carrier.
Recent tests to qualify the Grafoil Paste have been conducted and demonstrate the sealant adequately prevents
- leakage, whereas fittings with no sealant experienced severe leakage.
Union Carbide will certify this as a nuclear grade material and will produce it commercially upon receipt of a purchase order.
The constituent materials are approved for use in a nuclear environment; thus, Grafoil Paste is promising as an unrestricted thread sealant;
- however, sealant life under operating conditions has yet to be established.
Summar of Current Status "We are currently negotiating a test program with Oak Ridge National Laboratory (ORNL) for candidate thread sealant materials to conclusively qualify unrestricted sealants.
This program is expected to be completed in six months.
In the interim, Grafoil tape is fully qualified yet recognized as being difficult to use.
Felpro HPS is acceptable for use up to 650 F and 107 rads."
Excerpts from the Bounds to Toto memorandum referenced in the corrective action response for CATD-30901-NPS-Ol are as follows:
"The original disposition to NCR W-231-P (Reference
- 3) stated that Teflon tape would no longer'e used at WBN after May 1,
- 1985, based on a decision by plant management.
This was noted
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 21 OF 27 in Nuclear Safety Review Staff (NSRS) Investigation Report Number I-85-383-WBN (T25 860317 981).
- Moreover, NSRS had verified removal of all Teflon tape from Power and Construction storerooms prior to September
- 1985, "Because of the lack of an easily applied alternative to Teflon tape, Watts Bar decided later to allow its use in areas outside the Reactor and Auxiliary Buildings.
This policy was reflected in Reference 5 and WBN Technical Instruction (TI) 35.
However, Nuclear Regulatory Commission (NRC) Inspection Followup Item (IFI) 390/85-32-01 was closed based on NCR W-231-P (Reference 2 and 3).
Reference 3 reflected the original plant intention to prohibit future use of Teflon tape and provided technical justification for allowing Teflon tape to remain on lines which do not reenter the reactor coolant system (RCS), until maintenance scheduling allowed its removal.
"The Watts Bar resident NRC inspector has raised questions recently about TVA's policy on the use of Teflon tape, The DNE limitations of 300 F and 104 rads contained in G-29, P.S.4.M.1.1 have not changed since their inspection in 1980.
The provisions of G-29M are adequate to define necessary requirements for use of Teflon tape in view of the fact that an adequate substitute has not yet been found.
NCR W-231-P may be redispositioned to delete the total ban on Teflon tape and accept use as defined in G-29.
"This policy is within the technical justification provided in the original disposition of NCR W-231-P.
"DNE concurs in part with the Teflon tape policy requested in Reference 1.
We are working with items 1, 2, and 4, but have difficulty with item 3.
We are working with your staff to resolve our problems with this item and will revise G-29 when mutual agreement is reached.
"Please add this memorandum as a reference in Sections 5
and 11 of completed NCR W-231'-P.
This will provide clarification of the WBN Nuclear Power policy on the use of Teflon tape."
~SN CATD No.
30901-S N-01 CATD 30901-SQN-01 was issued to SQN line management to address the lack of employee familiarity with Teflon tape usage and to address the adequacy of Standard Practice SQA-160.
The acceptable response to this CATD received from SQN line management was as follows:
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 22 OF 27 t
d clarify 1 plicat5kCl thea a
matatzons may use tape d 9356."
D No. 30901-S N-02 CA Sg pr Te I
BFN d
shit
'stent po icy or usage of CATD No. 30901-BFN-01 CATD 30901-BFN-01 was issued to BFN line management noting a
lack of a tracking mechanism to ensure that Teflon tape will be replaced before it begins to break down due to exceeding its radiation dose restrictions.
BFN line management has responded as follows:
"A tracking mechanism is not needed to ensure the removal of Teflon tape before radiation induced breakdown.
A recent memorandum to Division of Nuclear Engineering (DNE) has requested that they define those system applications.
and environments where the use of Teflon tape should be controlled or prohibited.
"BFN plans to remove the Teflon tape from those areas indicated by DNE on an "as maintenance is performed" basis.
This is in agreement with the recommendations made regarding a
similap problem at Watts Bar Nuclear Plant.
It is also a
reflection of prior nuclear utility experience which has no stress corrosion cracking directly attributable to the breakdown of Teflon tape.
This includes nuclear facilities with longer operating lifetimes than BFN. It should be noted that radiation doses exceeding 10~ Rads often do not occur until near the end of the plant's life, Also, data shows that Teflon used as a sealant has a radiation stability up to 2.7 x
10 Rads.
The removal of Teflon tape in the manner described should be timely enough to avoid exposures that would cause the breakdown of Teflon tape.
The initiation of this action would therefore preclude the necessity for a tracking mechanism."
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE'23 OF'7 6,1.2 Element 309.04 - Procedure Violations WBN CATD No.
30904-WBN-01 CATD 30904-WBN-01 was issued to WBN line management noting that Maintenance Request (MR) forms do not provide for verification that the equipment or systems affected by the MR have been either returned to normal configuration or covered by a TACF at the time the MR is closed.
The acceptable WBN line management response was as follows:
"Administrative Instruction (AI) 9.2 standardizes guidelines for the preparation and review of Maintenance Request (MRs).
Step 17 requires that in the preparation of the MR, instructions be provided for return of equipment to normal status as required.
When MR instructions are followed and block number 27 on the MR form is signed off, the equipment has been returned to normal, or the appropriate Temporary Alteration Control Form (TACF) is referenced.
When mistakes are discovered they will be documented'by a Corrective Action Report (CAR), or Deviation Report (DR), or Condition Adverse "to Quality (CAQ) when applicable."
6.1.3 Element 309.05
- En ineerin Trainin Six CATDs were issued to address the concern for inadequate formal training for engineers with system responsibility.
One CATD was issued to Corporate Training and another to POTC.
The remaining four CATDs were issued to WBN line management.
NPS CATD No. 30905-NPS-Ol CATD 30905-NPS-Ol issued to Corporate Training noted that the WBN site procedure for technical staff training (AI-10.1) does not apply to site personnel from DNE,
- DNC, DNQA, or NSKL.
Furthermore, the CATD noted that the AI is not responsive to the TVA upper tier procedure which specifies training for site assigned personnel (Area Plan 0202.17).
Finally, the CATD noted that there were no responsibilities assigned to ensure that this training program is accomplished.
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 24 OF 27 The response to CATD 30905-NPS-01 is as follows:
Excerpts from the memorandum from Pedde, Acting Director to Nuclear Construction to Johnson, DNT, dated May 21,
- 1987, states the responses to CATD 30905-NPS-01:
"General - DNC has issued PMP 0202.17 as Construction/
Modification Interim Procedure CMIP-23.
"Browns Ferry Nuclear Plant - Modifications (BFN-MODS) presently has 35 degreed engineers and nine managers within the scope of the required training specified by PMP 0202.17.
Waivers will be initiated for those personnel ho qualify in the areas listed as items b, c, and d, in section 6.2.
Four engineers included in the count above have completed training Section 6.2.e.
"Sequoyah Nuclear Plant - Modifications (SNP-MODS) has presently submitted their needs for training in PMP 0202,17 through the Site Director's Organization.
To prevent a
double count on your rolls, I refer you to the site director's identified training needs.
litany of the MOOS personnel have completed this required training.
8+
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C "Watts Bar Nuclear Plant - Modifications (WBN-MODS) intends to have approximately 130 managers and engineers'rained to the requirements of Technical Staff and Manager Training for Nuclear Site Personnel by the end of the second quarter of 1988.
By mid-July of this year, approximately 30 individuals will have completed four weeks of training.
In addition, another 19 individuals will have completed the two-week Plant Systems Familiarization Course.
"Bellefonte onsite engineer training is contingent on operational plant staffing."
Excerpts from the memorandum from Sain, Assistant Director, DNT to McAnally, Corrective Action Program Manager,
- WBN, dated July 7, 1987 states:
"Actions were set in motion April 8, 1987 to resolve this issue.
By formal memorandum, each site director was requested to revise their respective training procedures to recognize the requirements in PMP 0202.17, "TECHNICAL STAFF AND MANAGER TRAINING FOR NUCLEAR PLANT SITE PERSONNEL," after which the DNT would provide a schedule for conducting the training following SQN Unit 2 restart, Additionally, the division directors of Nuclear Safety and Licensing, Nuclear Construction, Nuclear Quality Assurance, and Nuclear I
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TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 25 OF 27 Engineering were informed of the request to the site directors and these division directors were asked to supply the number and location (site) of the affec engineers from their respective divisions.
They wer ad 'sed of the tentative schedule to begin this traini folio '
SQN Unit 2 restart.
"The action plan described bove is app p iate and adequate to resolve this issue.
T e ining c tment in this area is long-term and with t 'orat of the requirements of PMP 0202.17 at eac
s u will be considered closed."
Excerpts from the du df Johnson to Lagergren, CEG Head,
- ONP, ed,
- 1987, are as follows:
"Responses h
e boOOt rpcd'y all divisions except DNE.
A meeting as d bf h o
ain of my staff with DNE represent i
itic y son and Don Evans on July 30, 3987 to discu s
e ineers participation in the Tech Staff
~a g
ntation Training Program.
An agreement was r a~~t E
ould define the onsite engineers that nee
~par p
e in this training to DNT.
DNE is pre evaluat'ng their onsite engineers and has agreed to provi
~this in rmation to DNT within three
- weeks, With this co tme from DNE, CATD 30905-NPS-Ol and -02 should be closed."
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CATD No.
30905-NPS-02 CATD 30905-NPS-02, which was issued to the
- POTC, noted that a
section of Area Plan 0202,17 is not accurate in that responsibility has been transferred from Supervisor, Personnel Service Staff to POTC.
The acceptable response recei'ved from the POTC was as follows:
"A revision to reflect proper responsibility in Section 4,4 of PMP 0202.17 will be submitted for approval by March '6, 1987,"
WBN CATD Nos.
30905-WBN-01 03 CATD 30905-WBN-01 issued to WBN line management noted that AI-10.1 does not implement the requirements of Area Plan 0202.17, and as a
- result, does not provide guidance for engineers.
- Also, CATD 30905-WBN-03 to WBN line management noted that AI-10.1 fails to provide sufficient detail on engineering training programs.
The acceptable response received from WBN line management for these CATDs was as follows:
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 26 OF 27 EtD'Pa6=g/~-O( KV/R:tXQH",C~ggg.,':,".::
202.17 o&
C Te anagers.
y May 29, 1987.
rea Plan 0202.17, Staff and ence Area Plan hnical Staff and location or assignment, rqet +y.,/HE,@qegdur~ <NP?~Q ~Training.
a a
~
horidbed at> aac'8"au53 ear.1jrtif fri8e;-ag4 also subj gpss yQpJ Oy Employee Training (GET) requirements"for the si$
!I for WattSNBar'..Nuclear P
t s
fi 'N AI~
training ofsDHE by thq DNE personnel ct to the General e, including those 10.1.
Technical site
'CATD No.
30905 -WBN-02 04 CATD 30905-WBN-02 noted that the orientation phase course implemented under Area Plan 0202.17 had n
een successfully completed by anyone via classroom at ance nd examination.
CATD 30905-WBN-0 WBN line m nagement noted
~that plant management is i ~ing.plant ersonnel to required training a
a Q~ptable re onse to these two CATDs was o
"T xc+Q anag r raining" P++2 Q+
s a fo f'4 gram that consists of g~) sep~4p cou, 9 - Plant Reforence Oc ia~ Qe>ig y',
and Organization Orientation, EGT320 glg51bar es, Standards, and Regulations rientatlo T321 - Plant Modification and Work Control
,lhl5>
~ )~$2 rie
- son, and SYS301 - Basis Systems.
Satisfactory c
pletion of all four (4) segments has not been attained by any NBN personnel, in thatto d.ate, no one 1igs attended all four courses.
Site management is rsaponsiblk for assigning personnel to attend these cour~a.
This prog am is presently scheduled to +,5'ffered'.'four times b
the end of
- December, 1987. ~fiona% elapses-we@
be sch duled based On POTC manp~ aVail'abide'itdj".n La+i,~it per fOr waivers e
be granite/
.to'lan+ gpr@A w
ave completed t
xng, What."exceeds he ger n
PHP 0202. 17.
p i.""To ensure that ~rop~
con and prior ity is placed on
'eeting.rain,iag commrtSents, a memorandum will be sent from the Site.Sirec~~o all WBN key managers stressing WBN's
~PC ommitment <b training.
Each key manager will be asked to royide an assessment of their respective training program
+9 and the degree of compliance.
I Rl I Rl
TVA EMPLOYEE CONCERNS SPECIAL PROGRAM REPORT NUMBER:
30900 REVISION NUMBER:
1 PAGE 27 OF 27
'Vnesnes,;Kj dsigilf)fink+ 'ega nraN 'gendas Az A85nical~Ptktf~dnd hkha'g"A Tth'Than be no
- managesgaemep~,ed akg+snn ilable
'raininQg
~ g 6.2 Corrective Action at Subcate or Level 0.1 ed and key or this No subcategory level findings were generated for this report for reasons discussed in Section 4.0., Therefore, there were no corrective actions at the subcategory level.
7.0 ATTACHMENTS Attachment A - Subcategory Summary Table Attachment B - Listing of Concerns by Issue Attachment C - Checklist for Root Cause Analysis Attachment D - Summary of Symptoms and Root Causes Attachment E - Graph of Symptoms versus Root Cause Attachment F - Bar Charts of Symptoms Attachment G - Bar Charts of Root Causes Attachment H - CATDs Attachment I - Evaluator List
Revision 1
30900 ATTACHMENT A SUBCATEGORY
SUMMARY
TABLE
REFEREt ECPS132J-ECPSIS2C FREQUENCY REQUEST ONP ISSS RWN ATEGORYI OP PLANT OPER.
SUPPORT TENNES ALLEY AUTHORITY OFFICE OF NUCLEAR POWER EMPLOYEE COtlCERtl PROGRAH SYSTEN (ECPS)
ENPLOYEE CONCERN INFORHATION BY CATEGORY/SUBCATEGORY SUBCATEGORY c 309 TECHNICAL TRAINItlG I
PA RUN RUN I
NE 13<36 i 5 DATE " 04/24/8 CONCERN NUNBER car SUB CAT S
H R PLT D LOC 1
REPORT APPL 2
SAF RELATED BF BL SQ WB HISTORICAL REPORT CONCERN ORIGIN COtlCLRtl DESCRIPTION REF.
SECT IO CAT OP SUBCAT 50 S<<ctloii/I s<<<<
IN 495-00101 T500CI3 OP 50805 S
WBN 1 tl N
N Y
2 NA NA NA NO 1
N N
N Y
2 NA NA tlA NO IN-85-CI95-001 QTC NORE TRAtttING IS NEEDED FOR CRAFT AN D EttGIttEf.RItlG PERSONNEL CONCERNING T HE TYPES OF EQUIPHENT FOUtlD Itl THE P
LANT.
INVERTERS p BATTERIES AND GENE RATOR EXCITATION WERE REFERENCED AS EXANPLES WHERE EQUIPtfEtlT TRAItlItlG IS NEEDED.
tlO FURTHER SPECIFICS ARE A VAILABLE.
3.'t 3f'9.05-l IN 595" 00801 OP 30901 N WBN I
N N
N Y
T50056 2
NA NA NA NO QTC HANAGEHEttf DID NOT REQUEST THE FIRE PROTECTION SYSTEN BE DRAINED PRIOR T
0 CRAFT DRlLLItlG ON THE SHUTDOWtl L IN ES.
THIS PROCEDURE IF DOtlE WITH QA LINES AF IER OPERATION WAY HAVE SERIO US CONSEQftEtlCES.
3.1 309.01-1 I
IN 704" 00201 OP 50901 N WBN 1
N N
N Y
T50064 2
NA NA NA NO QTC 2ND AND 3RD SHIFTS OFTEN DO NOT HAVE 3.1 ACCESS TU DRAWINGS RELATED TO INSTR 309 01 3
UHEttTATIOtt ACTIVITIES.
TVA NEEDS A
LIBRARY WHICH IS AVAILABLE2%
HOURS A DAY.
IN 825-00201 T50086 OP
= 50801 S
WBN 1
N N
N Y
2 NA NA NA SR 1
N N
N Y
2 NA NA
~ NA SR I-85 559-WBtt QTC TVA HAS SEVERAL PROCEDURES WHICH NEE D TO HAVE f'ROTIONS RFWRITTEN FOR CLA RITY OR NORE DEFINED CRITERIA.
EXAH PLES ARE fl-27 PART 5 ("COGtlIZANT EN GItlEER SHALL DETERHIttE ACCEPTAtlCE AS IT APPL)ES...".
NO HETHOD OF DOCUH ENTING TH1S ACCEPTANCE EXISTS. )
HIA
-14
( NCOGtt [ZAttT ENGIIlEER OR QUALIF IE D PERSONIIt L CAN COHPLETE THE DATA SH EET AS AI'i'ROPRIATE".)
NO DEFINATION OF " QUALIFIED PERSONNEL" EXISTS.
3.1 309.01-3 IN 977-00101 T50112 OP 50901 N
WBN 1
Y Y
Y Y
2 SR SR SR SR I-85-SBS-WBtt QTC TVA HAttAGEHEttT HAS STAlED THAT TEFLO N TAPE WHICH WAS USED Otl THE REACTOR COOLAtlf SYSTEH (RCS)
NUST BE IDEtlTI FIED AND Rf.l'LACED WITH ANOTHER TYPE OF TAPE.
tlOWEVERp NO PROGRAH TO ACCO
'PLISH t ttfs TASK HAS STARTED.
CI HA S
NO ADDt I fOtlAL IttFORHATION.
3.1 309.01-4 CONCERNS ARE GROUPED BY FIRST 3 DIGITS OF SUBCATEGORY ttUHBER.
REFERENCE ECPS132J-ECPS132C FREQUENCY REQUEST ONP ISSS -
RWN CATEGORY>
OP PLANT OPER.
SUPPORT TENtlESSEE VALLEY AUTHORITY OFFICE OF tlUCLEAR POWER EMPLOYEE COtlCERtl PROGRAM SYSTEN (ECPS)
EMPLOYEE COtlCERtl ItlFORthATIOtl SY CATEGORY/SUBCATEGORY SUBQATEGORYi 309 PROCEDURE/VIOLATIONS 1
I PAGE RUN TINE " 13 s 36 RUH DATE 04/24.
S H
SUB R PLT CONCERN NUMBER CAT CAT D LOC 1
REPORT APPL 2 SAF RELATED SF BL SQ WS HISTORICAL CONCERN REPORT ORIGIN CONCERN DESCRIPTION REF.
SECT CAT SUBCAT-IN 984-00201 OP 30904 N
WBN T5015ij 1N'N N
Y 2
NA NA NA SR QTC Section/Issue SPECTION CRITERIA - ITEMS ARE ACCEPT 3
ED THAT Dll tlOT NEET APPROVED DESIGN.
~ 2 EGi 1 -
LADDERS ON FILTER CUBICLES 309.04-1 IN UtlIT Cl AtlD COMMON AUXILLIARYBLD G.
AT 676', 692'tlD 737'LEVATIONS WERE CUT AtlD DIDN'T NEET DESIGN.
E Ga 2
3" THICK EtlCLOSURE (4'0" X 3' "X5'0") AT A-6 AND U LINE WAS RE-AS SENBLED BY tlUCLEAR POWER BUT DIDN' NEET APPROVED DESIGN (CLOSURE PLATE WAS LEFl OFF).
CI HAS NO FURTHER IN FORNATIOtl.
CONSTR.
DEPT.
CONCERN.
CI HAS tl0 FURTHER INFORNATIOtl.
H N
N Y
T50118 2
HA HA NA NO IN 209-00501 OP 30905 H
WBN 1
N N.
N Y
T50218 2
HA NA NA NO QTC QTC CI IS COtlCFRtlED THAT PERSONNEL PERFO RNING TECHtlICAL REVIEWS OF TESTS/DAT A ARE tlOT TRAINED tlOR HAVE THE EXPER TISE TO DO SO.
(DETAILS KtlOWH TO ER 3 ~
Ti WITHFLD TO NAINTAItl COHFIDENTIALI309.05-2 TY).
NUCLEAR POllER CONCERN.
CI HAS NO FUR(HER ItlFORNATION.
EHGItlEERS ASSIGNED SYSTEM RESPONSISI LITY SHllULD BE ABLE TO UtlDERSTAND SY STEN OPI'RA I IOtlS.
THERE HAS TO BE A FUtlCTIOllhl RELATIONSHIP BETWEEN HIS 3
~
COMPREtllllS10tl OF THE OPERATOR'S WORK309.05-3 AS IT Rl I ATES TO SYSTEN DESIGll CONT ROL.
Nl:Il htlD INEXPERIENCED ENGINEER S
WHO DO llllf HAVE THIS TRAItlIHG COUL D POTEtll IAI I.Y NAKE ERRORS RESULTING IH NOW-COHl'ORNIHG CotlDITIONS Attn RE WORK OF llA1 1;RIAL/EQUIPMENT.
THIS AP PL IES I 0 NUC POWER p COtlSTRUCTION AN D NAItlTEHAIlCE EtlGINEERS.
AT THIS TI NE tlO FORthAL TRAINItlG PROGRAM EX CONCERNS ARE GROUPED SY FIRST 3 DIGITS OF SUBCATEGORY NUMBER.
REFERE.
ECPS132J "ECPS132C FREQUE
- REQUEST ONP ISSS RHN
- ATEGORYs OP PLANT OPER.
SUPPORT TEtltlE ALLEY AUTHORITY OFFIC NUCLEAR POHER EMPLOYEE COtlCERN PROGRAM SYSTEN (ECPS)
ENPLOYFE CONCERtl ItlFORMATION BY CATEGORY/SUBCATEGORY SUbCATEGORY ~
309 TECHtllCAL TRAINING R
NE - ]3s36s RUN DATE - 04r24r SUS CONCERN NUNSER CAT CAT S
H R PLT D I.OC RFPORT APPL 2 SAF RELATED BF Bg SQ WB HISTORICAL CONCERN REPORT ORIGIN COIICERII DESCRIPTION REF.
SECT1 CAT
(
SUSCAT IN -d6-209-01201 OP 30905 N
WSN T5021d N
Y Y
A NA SR SR QTC Section/Issue PERSOtltlEL PERFORNItlG STA (SHIFT TEC ICAL ADVJSOR)
TRAINItlG ARE ENGINEERS 3
3 WITH LI I ILE OR NOT EXPERIENCE AS AN STA THEI4SL'LVES.
IT HAS tlOTED THAT 309.05"4 TWO PERSONS THAT HERE BEItlG PROCESSE D THROUGII 5 PARTICULAR STA CLASS HE RE SCHEI)ill t'I) TO TEACH THE tlEXT CLASS OF STA'S.
EtlGItlEERS ARE BEING ASSI GNED THE IASK OF TRAItiItlG STA'S IN P LAIIT OPlkhl IOtlS, OF WHICH THEY THENS ELVES HAVI LITTLE OR tl0 EXPERIEtlCE.
CI HA IUI ADDITIONAL ItlFORNATION.
NUC.
POWLII DEPT.
COtlCERN.
N N
N Y
2 NA NA NA NO OMP TI'S ARF ItlCORRECT OR INCOMPLETE.
F OR EXAMI'Il.
Otl 1-LPF-1 "116 d 1-LPF-1
-115 TIIC lnllPUTS ARE SHOWN AS NILLIV OLTS Htll II IIIE ACTUAL OUTPUT IS KBH 0 N THE Clllll'UIER PRINTER)
BOTH OUTPUTS SHOULD IIL SHOHN ON THE TI'S.
3,]
309.0]-5 XX -d5-122-02301 OP 30d04 S
BLN 1
N Y
N N
T50214 2
NA SR NA NA 02 OP 30906 S
SLN 1
N Y
N N
2 NA SR NA NA 11 CONCERNS FOR CATEGORY OP SUBCATEGORY 309 QTC BELLEFOIITEi OUT OF SERVICE TAGS FOR VALVES, I:lECTRICAL EQUIPNEtIT p ETC. p HAVE BEEtl VIOLATED EVERYWHERE.
THIS PRESENIS All EXTRENELY SER10US PERSO NNEL SAFEIY PROSLEN.
CI HAS NO FURT HER INFORMATION.
ANONYMOUS COtlCERN VIA LETTER.
3.2 309.04-2 COtlCERNS ARE GROUPED BY FIRST 3 DIGITS OF SUBCATEGORY NUMBER.
Revision 1
30900 ATTACHMENT B LISTING OF CONCERNS BY ISSUE The Engineering Subcategory (30900) is comprised of 11 concerns grouped into 3
elements addressing 11 issues.
Element 309.01 - Ade uac of Procedures Issue 309.01-1 Management did not require Fire Protection System drained prior to maintenance.
(IN-85-595-008)
Issue 309,01-2 Backshifts have no access to plant drawings.
(IN-85-704-002)
Issue 309.01-3 Procedures lack clarity and acceptance criteria.
(IN-85-825-002)
Issue 309.01-4 Teflon tape is not adequately controlled.
(IN-85-977-001)
Issue 309,01-5 Technical Instructions are incorrect and incomplete.
(WBN-243NS)
Element 309.04 - Procedure Violations Issue 309.04-1 Lax inspection criteria (IN-85-984-002)
Issue 309.04-2 Violation of Out-of-Service tags.
(XX-85-122-023)
Element 309.05
- Technical Trainin Issue 309.05-1 Training on actual plant equipment.
(IN-85-495-001)
Issue 309.05-2 Issue 309.05-3 Issue 309.05-4 Personnel performing technical reviews are not properly tr ained.
(IN-86-091-001)
System Engineers do not get adequate formal training (IN-86-209-005)
Inexperienced Shift Technical Advisor (STA)
Course Instructors.
(IN-86-209-012)
ATTACHMENT C Revision 1
30900 Checklist for Root Cause Analysis 1.
Procedure lacks specifics to perform task.
2.
Personnel lack sufficient training in the applicability/use of procedure.
3.
Lack of understanding regulatory requirements or commitments.
4.
Lack of adequate
- system, process, or administrative controls to ensure commitments are reflected in procedures or processes.
5.
Inadequate communication within functional group.
6.
Inadequate communication between functional groups.
7.
Management Assumed Risk.
8.
Procedures incomplete or failed to incorporate all technical requirements.
9.
Error in judgment by qualified individuals.
10.
Unqualified individuals performing the task.
11.
Insufficient time to perform task.
12.
Inadequate prerequisites defined to ensure satisfactory completion of task.
13.
Personnel performed task knowingly in violation of procedure/process.
14.
Personnel error in following procedures.
15.
Failed to identify root cause of previous deficiencies.
16.
Failed to take appropriate action to preclude reoccurrence.
17.
Inadequate process to detect adverse trends.
18.
Inadequate acceptance criteria defined to ensure satisfactory task completion.
19.
Management attentiveness to trends 20.
Lack of accessibility to documentation.
21.
Inadequate controls for review of results to ensure compliance with commitments.
22.
Timeliness of changes to commitments or changes to licensing/regulatory requirements.
23.
Isolated incident.
24.
Random error.
t 25.
Other - i.e.,
equipment related failure.
Page 1 of 1
ATTACHMENT D
SUMMARY
OF SYMPTOMS AND ROOT CAUSES Revision 1
30900 Element 309.01 Ade uac of Procedures For this element, there was the potential for negative findings at the subcategory level exhibited by the following symptom:
Inadequate work control (use of consumables).
This symptom appeared only in the evaluation for SQN.
As this symptom was tested for root cause, the appropriate root causes and applicable plant site were judged to be as follows:
a.
Procedures incomplete or failed to incorporate all technical requirements (SQN) b.
Failed to take appropriate action to preclude recurrence (SQN) c.
Inadequate controls for review of results to ensure compliance with commitments (SQN)
Element 309.04 Procedure Violations For this element, there was the potential for negative. findings at the subcategory level exhibited by the following symptoms:
a) Inadequate Work Control (modification activities),
and b) Inadequate Configuration Control (maintenance activities).
As these symptoms were tested for root cause, the appropriate root causes and applicable plant site were judged to be as follows:
a.
Lack of understanding regulatory requirements or commitments (WBN) b.
Lack of adequate system or administrative controls to ensure commitments are reflected in procedures or processes.
(WBN) c.
Procedures incomplete or failed to incorporate all technical requirements (WBN) d.
Inadequate controls for review of results to ensure compliance with commitments (WBN)
Element 309.05 En ineerin Trainin For this element, there was the potential for negative findings at the subcategory level exhibited by the symptom of "procedural non-compliance (non-regulatory required training)."
This symptom appeared only in the evaluation for WBN.
- However, based on the findings at WBN, additional evaluation will take place at SQN and BFN and will be reflected at category level.
The testing of the symptoms led to the following two root causes for WBN:
a.
Inadequate communication between functional groups (WBN Training Department with DNE,
- DNC, DNQA, DNSSL)
Page 1 of 2
Revision 1
30900 ATTACHMENT D (continued) b.
Procedures incomplete or failed to incorporate all technical requirements (WBN administrative instruction for technical staff training).
The analysis of the symptoms and root causes in the subcategory is depicted graphically in Attachments E,
F, and G.
Attachment E is a plot of each element's symptoms versus the root causes pointed out by the symptom.
Root cause numbers on the horizontal axis correspond to the 25 items on the "Checklist for Root Cause Analysis" found in Attachment C.
Attachment F
contains bar graphs showing the number of times each of the symptoms identified for the subcategory occurs for the various plants.
Symptom numbers on the horizontal axis in this attachment correspond to the symptoms as listed in Attachment E.
Attachment G contains bar graphs showing the number of times each root cause appears in the subcategory for the various plants.
I Rl I Rl I Rl Several observations can be made in studying the attachments and the findings section of this report.
A shared symptom of Inadequate Work Control was found at SQN (use of consumables) as well as WBN (modification activities).
Most.
significantly the two root causes of most frequent occurrence were a) procedures incomplete or failed to incorporate all technical requirements, and b) inadequate controls for review of results to ensure compliance with commitments.
Each of these root causes appeared at two of TVA's four nuclear sites.
Page 2 of 2
ATTACHMENT E SYMPTOMS VS ROOT CAUSES SUBCATEGORY 309 Revision 1
30900 S~mts ms 1.
Inadequate Work Control (use of consumables, modification activities) 2.
Inadequate Configuration Control (maintenance activities) 3.
Procedural Non-compliance (non-regulatory required training)
I I
I KEY:
W
= *WBN I
S
=
SQN I
I B
=
BEN I
I Element 309.05 3
SI Yl Ml Element Pl 309.04 2
Tl Ol Ml S I Element 309.01/
1 309.04 I
I I
I W
W I
S S
S I 1234567891011121314151617181920212223242' Root Causes
OCCURRENCES VS. SYMPTOMS SUBCAT 309 Vl Oz4IlL V
OO o
5 d
SYMPTOMS 10 OA O w O Ol 0
t OCCURRENCES VR SYNPFON'8 suBCAT 30Q
OCCUBBENCES VS. BOOT CAUSES SUBCAT 309 N
Ox RDOUO Q
l%
0 2
3 4
5 6
7 8
9 1011 12131415161718192021 22232425 ROOT CAUSES O
0
OCCUBBENCES VS. BOOT CAUSES I 0 0 4 ~ ~ f 0 ~ I~ 11101014101 ~Ifltlttttlttttt4tt SOOt CAlCX0 I 0 0 4 ~ ~ f ~ ~ I~ I~ 1010141 ~ I~ If1 ~ 1004 ~ I 00000400 SlkN CtQCZ0 IQ O
oe C)OV 0
0 0 4 0 ~ 0 0 0 101110%141 ~ I~ifitlttttStttttltt IKNR CSWSC0 0 4 ~ 0 0 ~ ~ 101110101410IOItl ~lttttl00000400 0001 Cta:000
Revision 1
30900 ATTACHMENT H CORRECTIVE ACTION TRACKING DOCUMENTS (CATDs)
CATD NUMBER CORRECTIVE ACTION PLAN RECEIVED/APPROVED 30901-NPS-01 30901-SQN-01 30901-SQN-02 30901-BFN-01 30904-WBN-Ol 30905-NPS-01 30905-NPS-02 30905-WBN-01 30905-WBN-02 30905-WBN-03 30905-WBN-04 Yes Yes Not applicable (Tracking Only)
Yes Yes Yes Yes Yes Yes Yes Yes
0 ECSP Corrective hction Irachi Document
~CkTD )
ECTG C.3 httachment h
Pate 1 of 1 Revision 2
INITIhTION 1.
2.
3'.
5.
6.
licable ECSP Re ort No.:
Fact Sheet 309.01-MBN Revision 1
Immediate Corrective hction Required:
Q Yes g No Stop Mort Recommended:
0 Yes
)if No ChTD No.
30901>>NPS-01 4.
ZNITIhTZON DhTE 3-12-87 RESPONSIBLE ORGhNZLLTZON:
Cor rate PROBLEM DESCRIPTION: 5-QL<"
pQR Identification of an acce table substitute for teflon ta 'as not been a
ressivel ursued.
Inconsistencies ezist between MBN BFN and S
N on the restrictions of use of teflon ta e.
7.
8.
9.
P REPhRED BY; NhME r
CONCURRENCE:
CEG-H hPPROVhL:
ECTG PROGRhM MGR.
8 hTThCHMENTS DhTE:
ac DhTE: 0 87 DhTE!
7
'CORRECTIVE hCTXON 10.
PROPOSED CORRECTIVE hCTZON PLhN:
~TThCHME S
11.
PROPOSED BY:
DIRECTO&
12.
CONCURRENCE:
CEG-R:
SRP:
ECTG PROGRhM MGR:
DhTE:
DhTE:
DhTE:
DhTE:
DhTE:
DhTE:
DhTE:
zs-VERIFICdTION END CLOSEOUT 13.
hyproved corrective actions have been verified as satisfactorily implemented.
1934T SZGNhTURE DhTE
ECSP Corrective hction Trackin Document Attachment h
Page 1 of 1 Revision 2
INITIhTION 1.
2.
3.
5.
6.
h licable ECSP Re ort No:
309.01 S
N Imaediate,Corrective Action Required:
IL Yes 0
No Stop Vork Reconiaended:
0 Yes 5
No CATD No.
30901-S N-01 4.
INITIATION DATE RESPONSIBLE ORGANIZATION:
Se uo ah PROBLEM DESCPXPTZON: 5 QR NQR;I(m
'es
>roA o
n S
Ce I h v'i gaD5, 11-12-86 7.
PREPARED BY:
NANE To t
8.
CONCURRENCE:
CEG-H
~
9.
APPROVAL:
ECTG PROGRAM NGR.
0 ATTACHMENTS D
E:
11-12-86 E:
CORRECTIVE hCTION 10.
PROPOSED CORRECTIVE hCTION g
Revels ndard Practice S hl60 to clarif 1imitations o
t ue memorandum to em lo ees
@ho ma use flo e
a of the restrictions on Teflon ta e
a licat n
tems tracked b
HATS 9357 and 9356.
0 ATTACHNENTS ll.
PROPOSED BY:
DIRE R
N 12.
CONCURRENCE:
CEG-H:
~
SRP:
ECTG PROGRAN NGR:
VERIFICATION AND CLOSEOUT 3 861029 802 DATE:
DATE:
DATE'ATE:
DATE:
DATE:
.DATE:
11-04-86 13.
Approved corrective actions have been verified as satisfactorily implemented.
2534T SIGNATURE TITLE DATE
ECSP Corrective Action Trackin Document
<CRTD1 ECTG C,3 Attachment A
Page 1 of 1 Revision 2
INITIATION 1.
2.
3 ~
5.
e.
e licshle ECSP Re oet No.:
309.01
~S N
Immediate Corrective Action Required:
0 Yes pf No Stop Mork Recommended:
0 Yes Jf No CATD No. 30901-S N-02 4.
INITIATION DATE 3-12-87 RESPONSIBLE ORGANIZATION: 4, e uo ah PROBLEH DESCRIPTION: iN Q NQR S
N hes no consistent
~ro ssm or olic to identif control and eliminate im ro er usa e of teflon ta e.
This is identified in Ch S P-870155 and this CATD is issued to track the closure of this t
7.
8.
9 ~
PREPARED BY:
NAME CONCURRENCE:
CEG-H APPROVAL:
ECTG PROG MGR.
0 ATTACHMENTS DATE:
-8 DATE: ~ 7 DATE:
7 CORRECTIVE 10.
i BUT ION PROPOSED CORRECTIVE ACT N
11.
PROPOSED BY:
DIRECTOR(NGR()
12.
CONCUkkENCE:
CEG-H:
SRP:
ECTG PROGRAM MGR:
VERIFICATION AND CLOSEOUT 0 ATTACHMENTS DATE:
DATE:
DATE:
DATE:
DATE:
DATE:
DATE:
13.
Approved corrective actions have been verified as satisfactorily implemented.
1934T SIGNATURE TITLE DATE
ECTG C.s Attachment i Page 1 of 1 Revision 2
ECSP Corrective hction Trackin Docmaent
+TTXLTION 24 3t
-5 6 ~
h licable ECSP Re ort No:
309.01-BFN Draft
\\
Immediate Corrective iction Required:
0 Yes Q
No Stop Mork Reccaaaanded:
0 Yes Q
No CATD No.
30901-BFN&1 4.
ZNXTXATXOMDATE 1-23-87 RESPONSIBLE ORGANIXliZON BFN PROBLE5 DESCRIPTION: lg QR 6 NQR Teflon thread sealin ta has been ased in violation of General Con'strnction S
cification G-29N Process S ecification 4-1.1-1.
No trackin mechanism is in lace to ensure that the ta vill be re laced before ft be ins to break dovn-dne to radiation dose in excess of 10'ads.
. 7'REPARED BY:
MME 8.
CONCQEKHCE:
CEG-9.
APPROVAL'CTG PRO CORRECTIVE hCTION.
Villiam
. h cock R.
~ ~
A A
4 (ti't 11.
PROPOSED BT:
DZRECTO 12 CONCURRENCE:
CEG-8:
C SRP:
ECTQ PROGRhlf NGR:
10.
PROPOSED CORRECTIVE hCTION PLAN.
DATE:
1-22<<87 L DATE'T-Zf'TE c'7
~
ta C
hTTACHNENTS DATE:
DATE:
DATE MTE:
MTE:
DATE:
DATE:
t
~ e
~A rr r
t-iel,f Eg
~Cr.
~ \\Pe (e
VERIFICATION AND CLOSEOUT 13.
hpproved corrective actions have been verified as satisfactorily implemented.
SIGNATURE
~
~
e t,
~
t
~<<~o.~..<<t'
~'i
~
t C
ECSP Corrective Action Trackin Document (CBED>
ECTG C.3 Attachment A
Page 1 of 1 Revision 2
INITIATION l.
2.
3.
5.
6.
A licable ECSP Re ort No.:
309.04 Immediate Corrective Action Reguired:
0 Yes I No Stop cwork Recommended:
0 Yes El No CATD No.
30904-MBN-01 4.
INITIATION DATE 01-17-87 RESPONSIBLE ORGANIZATION:
MBNP Maintenance Su erintendent PROBLEM DESCRIPTION:
Q QR S
NQR ECTG evaluation (attached) revealed that Maintenance Reouest forms do not rovide for verification that the e ui ment or s stem affected b
the MR has been either returned to normal conf~ uration or covered b
a TACF at the time the NR is closed.
7.
PREPARED BY:
NAME V. L. Avcock 8.
CONCURRENCE:
CEG-9.
APPROVAL'CTG PROGRAM MGR.
CORRECTIVE ACTION 8 ATTACHMENTS DATE:
01-15-87 mc. DATE:
~ m 6'F.
DATE:
10.
PROPOSED CORRECTIVE ACTION PLAN:
Q AT ACHMENTS 11.
1 2 E
P ROGRAM MGR:
PROPOSED BE:
DZRECEORCMORB
~ :.. "
~(l.
DJLE"-:
CONCURRENCE:
CEG-H:
'. iC.
DATE:
SRP:
DATE:
DATE:
DATE:
DA,TE:
DATE:
+ ig/Lg C
wC C1~
VERIFICATION AND CLOSEOUT 13.
Approved corrective actions have been verified as satisfactorilY implemented.
2965T SIGNATURE TITLE DATE
ECSP Corrective Action Trackin Document a4LU Attachment h
Page 1 of 1 Revision 2
INITIATION h
licable -ECSP Re ort No.:
309.05-WBN 1.
2 a 3
~
5.
6.
Immediate Corrective Action Required:
0 Yes g
No Stop Mork Recommended:
0 Yes R
No CATD No.
30905-NPS-01 4.
1NLTIATION DATE 2-13-87 RESPONSIBLE ORGANIZATION:
Cor orate Trainin PROBLEM DESCRIPTTON: 0 QR H NQR MBN AI-10.1 is not a
licable to site ersonnel from DNE DNC DN h or NSSL.
Further AI-10.1 does not address brea Plan 0202.17 which s ecifies trainin for site
~assi ned ersonnel from ONE ONC ON h and NE&L
.These is no direction or res onsibilit assi ned to ensure t t this training
~ro ram is accom lished.
7.
PREPARED BY:
NAME T. V. White 8.
CONCURRENCE:
CEG-H 9.
APPROVAL:
ECTG PROGRAM M
ATTACHMENTS D T '-13-87 X-6-eg ATE:
2-(8 -d 7 CORRECTlVE ACTION 10.
PROPOSED COR See attac g
u
/
9fP Verbal concurrence,bv T. Huth ECTG to W
r f 4
EN rch 87 0 ATTACHMENTS 11.
PROPOSED BY:
DIRECTO /MP:
12.
CONCURRENCE:
CEG-H:
~P.
J <7-~-3~
ECTG PROGRAM MGR:
dew - DATE:
B Ne 7
DATE: ~i -8 7 DATE:
DATE:
DATE:
DATE:
VERIFICATION AND CLOSEOUT 13.
Approved corrective actions have been verified as satisfactorily implemented.
3749T SIGNATURE TITLE DATE
ECTG C.3 httactunent h
Pate 1 of 1 Revision 2
0 ECSP Corrective hction Trackin Document (CkTD>
-INITIdTION l.
2 ~
3.
5.
e.
d licable ECSP Re ort No.:
30905-MBN Immediate Corrective dction Required:
0 Yes S
No Stop York Recommended:
0 Yes R
No ChTD No.
30905-NPS-02 4.
INITIdTION DdTE 2 87 RESPONSIBLE ORGhNIZhTION:
POTC PROBLEM DESCRIPTION: 0 QR B NQR drea lan 0202.17 revision 0
Februar 12 1986) section 4.4 is not accurate res onsibilit has been transferred from su ervisor Personnel Service Staff to POTC.
7.
PREPhRED BY:
NhÃE T. M. Mhite 8.
CONCURRENCE:
CEG-8 9.
hPPROVdL:
ECTG PROGRdM'MGR.
H dTTdCHMENTS DhTE:
2-13-87 NA:~f CORRECTIVE dCTION 10.
PROPOSED CORRECTIVE dCTION PLhN:
11.
PROPOSED BY:
DLRECTOQMGR:
12.
CONCURRENCE:
CEG-H:
SRP:
ECTG PROGRdM MGR:
0 hTTdCHME TS I
s DhTE:
~ DhTE:
DhTE:
DhTE:
DhTE:
DdTE:
DdTE:
VERIFIChTION hND CLOSEOUT 13.
dpproved corrective actions have been verified as satisfactorily implemented.
3749T SIGNhTURE TITLE DhTE
htt~Peent h
Paje 1 of 1 Revision 2
ECSP Corrective Action Trackin Document ittTC)
INITIATION 1.
2 ~
3.
S.
6.
h licable ECSP Re ort No.:
309.05-MBN Ittoediote Correctiee dctioo Required:
0 Teo ~
No Stop Work Recommended:
0 Yes + No CAID No.
30905-iSN-01 4.
INITIATIONDATE 2-13-&7 RESPONSIBLE ORGANIZATTON:
VBN Site Director PROBLEN DESCRIPTION: 0 QR NQR WBN AI-10.1 "Plant Trainin Pro ran revision 21 Se tember 26 1986 does not include the Nana er Trainin for nuclear lant site ersonnel.'s a result
.AI-10.1 does not rovide uidance for en ineers as re aired b
0202.17.
7 ~
8.
9.
PREPARED BY:
NANE T.
M. @hite CONCURRENCE:
CEG-8 APPROVAL:
ECTG PROGRAÃ KG TTACHNENTS 5
Dh Z
l3 8 Iv 8 E:
7/C CORRECTIVE 10.
ACTION PROPOSED CORRECTIVE ACT P
ll.
PROPOSED BY:
DIRECTOR/
G A
12.
CONCURRENCE:
CEG-8:
SRP:
ECTG PROGRAÃ NGR:
0 ATTACHMENTS DATE
~ DATE:
DATE:
DATE:
DATE:
DATE:
DATE:
VERIYICATION AND CMSEOUT 13.
Approved corrective actions have been verified as satisfactorily implemented.
3749T SIGNATURE TITLE
ECTG C.3 dtt~~ent d
Paje 1 of 1
Revision 2
ECSP 'Corrective Action Trackin Document (ClTD>
INITIATION 1.
2 ~
3.
5.
6.
h licable ECSP Re ort No.:
. 309.05-MBN Immediate Corrective Action Require/:
0 Yes I5 No Stop Work Recommended:
Q les ~
No CATD No.
30905-MBN-02 4.
INITIATIONDATE 2-13-87 RESPONSIBLE ORGANIZATION:
MBN Site Director PROBLEli DESCRIPTION 0 QR NQR Area Plan 0202.17 "Technical Staff and Nana er Trainin f r Nuclear Plant Site Personnel (revision 0
Februar 12
,1986)
@as reviewed or im lementation at MBN.
At the time of this evaluation the urs had been offered twice in 1986.
Data indicates that no on has suc ssfull corn leted the course via classroom atte ance and ex
'nation.
Onl five ersonnel have "corn leted" this c rse due to
'vers based on havin corn leted more stria ent trai n
'e STh ATTACHNENTS Ff 7.
PREPARED BT:
NAME T. M. Mhite DATE:
2-13-87 8.
CONCURRENCE:
CEG-H 9.
APPROVAL:
ECTG PROGRAM NGR.
DATE:
Z/4 ~l CORRECTIVE ACTION
/
10.
PROPOSED CORRECTIVE ACTIO 11.
PROPOSED BX:
DIRECTOR G
12; CONCURRENCE:
CEG-H:
SRP:
ECTG PROGRAM NGR:
VERIFICATION AND CLOSEOUT Q ATTACHNENTS DATE:
DATE:
DATE:
DATE:
DATE:
DhTE:
DATE:
13.
Approved corrective actions have been verified as satisfactorily implemented.
3749T SIGNATURE DATE
ECSP Corrective Action Trackin Document jckTD)
Attachment h
PajW of 1 Revision 2
INITIATION l.
2 ~
3 ~
5 ~
6 ~
A licable ECSP Be ort No.:
309.05-MBN Imaediate Corrective Action Required:
0 Yes S
No Stay Uoek Reeaaaaendad:
0 Yes + No CATD No.
30905-NN-03 4.
INITIATION DATE 2-13-87 RESPONSIBLE ORGANIZATION:
VBN Site Director PROBLBt DESCRIPTION: 0 QR QR MBN AI-10.1
'Plant Trainin pro ram 'evision 21 Se tember 26 1986 fails to rovide sufficient detail on en ineerin trainin ro rams.
This document should s ecif the t e and sco e of traini for Technical Staff and mana er as identified in Area Plan 020 7.
8.
9.
'0RRECTIVE 10.
PREPARED BY:
NATE T. Q. White CONCURRENCE:
CEG-H APPROVAL:
ECTG PROGRNf KGR.
ACTION PROPOSED CORRECTIVE ACT N@
i hTTACHNENTSre DATE:
2-13-87 7
11.
PROPOSED BY:
DIRECTOR/
12.
CONCURRENCE:
CEG-H:
SRP:
ECTG PROGRAM NGR:
0 ATTACHNENTS DATE: W
? P DATE:
DA.TE:
DATE:
DATE:
DATE:
VERIFICATION AND CLOSEOUT
- 13.
Approved corrective actions have been verified as satisfactorily implemented.
3749T SIGNATURE TITLE DATE
httachment h
Page 1 of 1 Revision 2
INITIhTION 1.
2.
3 ~
5.
6.
ECSP Corrective Action Trackin Document CATD d
licable ECSP Re ort No.:
309.05-VBN Imaediate Corrective Action Required:
0 Yes 5
No Stop York Recoaaaended:
0 Yes Of No CATD No.
30905-UBN-04 4.
INITIATIONDATE 2-13-87 RESPONSIBLE ORGANIZATION:
VB Site Director PROBLEM DESCRIPTION: 0 QR NQR From the evaluation erformed on 309.05-MBN it is determined that lant mana ement is lar in sendin lant rsonnel to r uired trainin ro r ams.
7.
PREPARED BY:
NAME T. V. White 8.
CONCURRENCE:
CEG-H 9.
APPROVAL:
ECTG PROGRAN NGR.
ATTdCHNENTSFS P lt ATE:
2-13-87 cJ~
DATE:
i
'7 CORRECTIVE ACTION e
10.
PROPOSED CORRECTIVE dCT See at a
Verbal c ll.
PROPOSED BY:
DIRECTO N
12.
CONCURRENCE:
CEG-8:
SRP:
ECTG PROGRAN NGR:
VERIiICATION AND CLOSEOUT 87 0 dTTACHNENTS ATE:
DATE:
DATE:
DATE:
DATE:
DATE:
13.
hpproved corrective actions have been ver'ified as satisfactorily implemented.
3749Tt f
SIGNATURE TITLE DATE
Revision 1
30900 ATTACHMENT I LIST OF EVALUATORS BY ELEMENT/PLANT Element 309.01 WBN G. Wenninger R. Jones BFN B. Aycock
~SN T. Massey T. Elliott BLN J. Muir Element 309.04 WBN B. Aycock J.
Manuel BLN J. Muir Element 309.05 WBN T. White
~SN M. Murphy